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Click here to subscribe to HRET Resources RSS feed Hand Hygiene Project: Best Practices from Hospitals Participating in the Joint Commission Center for Transforming Healthcare Project

- November 01, 2010

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Hand Hygiene Project: Best Practices from Hospitals Participating in the Joint Commission Center for Transforming Healthcare Projects.  Hand hygiene was chosen by eight leading hospitals for the first Robust Process Improvement (RPI) project by the Joint Commission Center for Transforming Healthcare. The Joint Commission had surveyed the hospitals and asked, “What is the number one patient safety challenge?†Hospitals prioritized the challenges, and hand hygiene ranked first on the survey.

Many health care-associated infections (HAIs) are transmitted by health care personnel, and hand hygiene is a primary means to reduce these infections. In 2002, the estimated number of HAIs in U.S. hospitals was approximately 1.7 million, with more than 98,000 deaths annually, according to the CDC.

The Eight Participating Hospitals
Mark Chassin, MD, Joint Commission president, chose the eight hospitals to participate in the hand hygiene project. These hospitals all had “well-established RPI infrastructure at their hospital,†said Melody Dickerson, RPI black belt, the Joint Commission. All eight hospitals use Lean Six Sigma methodologies, and it was a requirement that the eight hospitals follow the same methodology throughout the project.

The Joint Commission standard for hand hygiene has changed as a result of the hand hygiene project. Previously the standard called for hospitals to demonstrate hand hygiene compliance at a rate greater than 90 percent. A hospital that failed to comply would receive a Requirement for Improvement (RFI) and have 90 days to show improvement to 90 percent. “Because of this project, we now know how difficult it is to reach 80 percent, let alone 90 percent,†said Dickerson. “Now the standard says the hospital needs to work to improve compliance,†she explained.

The eight hospitals are:

  • Cedars-Sinai Medical Center, California: 950 beds, teaching
  • Exempla Lutheran Medical Center, Colorado: 400 beds, nonteaching
  • Froedtert Hospital, Wisconsin: 486 beds, teaching
  • The Johns Hopkins Hospital, Maryland: 1,041 beds, teaching
  • Memorial Hermann The Woodlands, Texas: 252 beds, nonteaching
  • Trinity Health?St. Joseph Mercy Health System, Michigan: 537 beds, teaching
  • Virtua, New Jersey: 270 beds, nonteaching
  • Wake Forest University Baptist Medical Center, North Carolina: 872 beds, teaching

In December 2008 representatives from these hospitals met to work on a charter and define the scope of the project, which is the first step in the five-step Six Sigma methodology: define, measure, analyze, improve, control. Most of the hospitals had tried tackling hand hygiene before participating in the Center’s project. For the participating hospitals—and for most hospitals beginning a similar project—the baseline data results, using non?biased hand hygiene observers or secret shoppers, were surprising in that the hand hygiene compliance demonstrated was much less than previously thought. Most hospitals thought their compliance rate was about 70 percent to 90 percent, when it was actually less than 50 percent. As one hospital champion observed, “Where we thought we were and where we were, were two different things.â€

From April 2008 through August 2010, the participating hospitals defined and measured hand hygiene, analyzed data, and improved processes and workflow using Lean Six Sigma. The hospitals helped identify 15 major root causes of failure to clean hands and worked on developing targeted solutions for each root cause or contributing factor.


  • As of August 2010, all eight participating hospitals reported hand hygiene compliance rates at about 82 percent, and they are still monitoring the process to determine sustainability of their results.
  • Many of the hospitals have reported a decline in HAIs as their hand hygiene compliance rate has increased.
  • Solutions developed by the hospitals are part of the Targeted Solutions Toolâ„¢ (TST), a webbased tool provided free to Joint Commission-accredited organizations. The TST allows organizations to customize solutions to address their specific barriers to excellent performance.

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